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Tuesday, August 31, 2010

3rd Party Reimbursement for Doulas ~ The A, B, C's

Welcome Guest Blogger April Kline! She shares with us how to unravel the mystery of 3rd Party Reimbursement!

Earlier today, I had a conversation with a friend who is a hypnobirthing professional. She isn’t a doula, but she was telling me about a birth she recently attended for a woman who did not have a doula. My friend commented that she could not believe the amount of love and energy it requires to be truly with a woman in her pregnancy and birth. She said she had a new respect for doulas and the work they do.

I don’t think any of us would argue that the work of a doula is necessary and important. All doulas can surely agree that this work is a labor of love, with many hours and untold amounts of energy poured into one woman’s pregnancy and birth. But what we do not always agree upon is whether there is a monetary amount that should be attached to the work we do. Doula fees vary widely from region to region, but even within a geographic area, prices vary from free to the top amount a given market will bear. Some doulas seem to think affixing a price to their services somehow lessens the sacredness of what we do. Others are much more practical and won’t even entertain the idea of working with a client who cannot pay their fee.

I believe an educated and experienced doula’s services are priceless. Since priceless is not an amount most clients can afford, I believe that we, as doulas, need to set our fees within the market of our region and in keeping with our education and experience. If we consistently charge anything less, we are only encouraging the belief that we are not professionals and that what we do is not valuable.

That said, there are several options we can offer clients that may make paying our fees a bit easier. The most common of these is to offer a sliding scale according to need. Most doulas offer some variation of this. Another option is to incorporate a specified number of free births you are willing to offer per year. It may be possible to write at least portions of these free births off as charitable work under some special circumstances, so check with your accountant if you are planning to incorporate this into your practice.

The other option is not so common, but is a growing trend. Over twenty insurance companies have begun paying for doula services and, now that there is a CPT code covering doula services, this is more of a possibility than ever before. (CPT stands for Current Procedural Terminology, and is a copyright of the American Medical Association.) The CPT code commonly used to claim doula services is 99499 for Evaluation and Management Services/Labor Support.

The fact that their insurance company might reimburse at least some portion of the fee for your services might make you attractive to a group of potential clients who might not have been interested before. Getting reimbursement for doula services requires patience and persistence, but it can be done. If you are going to offer this as a possibility for your clients, you will also need to be willing to offer some guidance and, most likely, a fair amount of support, as they attempt to get reimbursed.

The following is a partial list of insurance companies have reimbursed in whole or in part for doula services.

Aetna Healthcare

AltPro

Baylor Health Care System/WEB TPA

Blue Cross/Blue Shield

Blue Cross/ Blue Shield PPO

Cigna

Degussa, a German Chemical Company

Elmcare, LLC, C/O North American Medical Management

Foundation for Medical Care

Fortis Insurance

Glencare Managed Health Inc.

Great-West Life & Annuity Ins. Co.

HNTB (Peoria, IL)

HoustonNew England Financial, Employee Benefits (Fort Scott, KS)

Humana Employers Health

Lutheran General Physician's Organization

Maritime Life

Medical Mutual

Oschner HMO, Louisiana

Professional Benefits Administrators

Prudential Healthcare

Qualchoice

Summit Management Services, Inc

Travelers

United HealthCare of Georgia (San Antonio, TX)

United Health POS

Wausau Benefits, Inc

So, you say you want to help your clients get insurance reimbursement. How do you go about making this happen? Let’s get down to the nitty-gritty.

Step 1:

Before you offer to help clients get insurance reimbursements, you will want to get your own National Provider Identification (NPI) number. In October of 2009, a new taxonomy code for doulas was approved by the National Uniform Claim Committee. This code allows certified birth and postpartum doulas to register for their own NPI number which makes it possible to submit to Medicaid and third-party insurance companies for reimbursement. According to the International Childbirth Education Association (ICEA), the new taxonomy code is 374J00000X and is called Doula under the heading of Nursing Service Related Providers Type. ICEA goes on to state, “While the term Doula is listed under the Nursing heading, RN or LPN licensure are not required to obtain the NPI number. The description includes the services of antepartum, labor doulas, and postpartum doulas.”

A definition of doula work is included on the National Uniform Claim Committee website: “Doulas work in a variety of settings and have been trained to provide physical, emotional, and information support to a mother before, during, and just after birth and/or provide emotional and practical support to a mother during the postpartum period.”

Applying for your own NPI number is simple and will only take you a few minutes online if you follow these instructions.

Log on to the National Plan & Provider Enumeration System website at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.instructions

Read over the required information and follow the links for applying for an NPI number

Complete the online application

Wait a few minutes, and an email will come to you with your very own NPI number

Yes, it really is that simple. And yes, it will make insurance companies and even Medicaid take you much more seriously.

Step 2:

Make an information sheet for your clients outlining the steps they should take to make reimbursement most likely. Note that it is best to have your clients pay you directly in full, and then attempt to get reimbursement from the insurance company for themselves. I strongly advise against offering to wait for payment until the insurance company pays your client. I even more strongly advise you against dealing with your client’s insurance companies directly – it is no fun and can leave you unpaid in the end.

The following is a thorough and easy-to-follow sample outline you can share with your clients. This outline describes the steps they can take to help them get reimbursed by their insurance companies for your doula services.

How to Request Insurance Reimbursement for Doula Services

___ Pay your doula in full.

___ Get an invoice from her which includes the following information:

a. The doula's name and address

b. Her social security number/taxpayer ID number or NPI number

c. The date and location services were provided

d. The CPT code for the services provided

e. A diagnosis code

f. The doula's signature

___ Submit the invoice with a claim form to your insurance company.

___ Within four weeks, expect a letter telling you either that

a. They need more information before they can process your claim.

b. This is not a covered expense.

___ Ask your Doula to send you the following:

a. A copy of her certification (if she is certified)

b. Other credentials or relevant training

c. A letter detailing her training and experience and what she did for you

___ If possible, ask your obstetrician or midwife for a letter explaining why a doula helped you, was necessary, or saved the insurance company money. (Did you have a high-risk pregnancy? Did the doula's suggestions appear to prevent complications or help your labor to progress more quickly? Did the doula's presence decrease your need for expensive pain medications?)

___ Write a letter explaining why you felt the need for a doula and how you believe the doula was beneficial to your health.

___ Submit to your insurance company: the doula's letter and credentials the letter from the doctor your cover letter

___ If they refuse it, write a letter to Health Services requesting that they review the claim, as you feel it was a cost-cutting measure and they should cover the cost.

___ Follow up by telephone if necessary.

___ If they refuse, write a letter to the CEO explaining why you feel that doula care should be a covered expense. They may not pay your claim, but they will consider it for the future. (Kelli Way, ICCE, CD(DONA) 1998. Reprinted with permission.)

Step 3:

Write a sample letter upon which your clients can base their own letters to their insurance companies. The following is an example of the letter that I have used with success.

To Whom It May Concern,

[Client's name], who is insured through your company, has retained my services to assist in the birth of her [number of birth] baby. [Client’s name] has hired me because she [include detailed information about the benefit your client was looking for: fewer interventions, expertise with VBACs, special assistance avoiding a particular procedure, etc.]. [Include other pertinent details here that might be persuasive to the insurance company including: how many hours you spent with your client in prenatals, at the birth and postpartum, exact services you provided, etc.]

Eleven controlled medical studies have shown that women who give birth with consistent doula support undergo fewer interventions including epidurals, forceps and vacuum-assisted deliveries, and c-sections, often have shorter labors, typically have shorter hospital stays, and overwhelmingly rate their labors and births with higher levels of satisfaction than women who do not have this support. Babies of mothers who are supported by doulas often experience less interventions and spend less time in the nursery or neonatal intensive care unit than babies born without doulas.

As a certified doula through [name of certifying organization] since [year of certification], I am uniquely qualified to provide the services [client name] was seeking. The CPT code for the services I provided is [CPT code]. My doula license number is [license number] and my NPI number is [NPI number].

If you need any additional information to pay this claim, please feel free to contact me at [your phone and/or email address].

Sincerely,

[Your name]

And there you go! Now you know how to offer assistance with insurance reimbursement to your clients. This can be helpful not only to your clients, but also to you as you grow your doula business.

12 comments:

Let me reiterate: it is often a frustrating experience dealing with third party reimbursement. But I believe it is important that we continue to petition insurers to cover our services... and sometimes, they actually do pay out!

I recieved word from a client that Group Health reimbursed her in full for my services using a form I have created and your form letter. woot! And I have applied for my NPI but it's still pending. :/ how long does it typically take? thanks!!

I really appreciate this concise, step-by-step guide. I had been debating about trying to apply for an NPI number since I learned about the Doula taxonomy code last year, but was afraid it would be too complicated. This helped get me over my fear and I got my number almost immediately! I cannot thank you enough for this post!

It would seem to me (I'm a doula who is not yet certified) that a practicing doula, certified or not, would still be able to have the NPI number. From the Health Care Provider Taxonomy Codes Set under doula, the description states that a doula is a "trained" person. Not necessarily a "certified" person. I, myself, have been professionally trained and have documentation for such. So I would think that if you were trained then you would still qualify. Possibly? Any thoughts?

Birthsource Blog ~ ChildbirthToday!

About Me

My passion is to bring evidence based information to both maternity professionals and expectant parents through personalized education, web-based media and social media. I am pleased to serve as President of the International Childbirth Education Association for 2015-2016.

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